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M.Sc. (Med.) (Child Health Neurodevelopment Option), Faculty of Health Sciences, University of the Witwatersrand, 2009 / Two public sector hospitals in Pietermaritzburg, KwaZulu-Natal, Edendale and Grey‟s have specialist clinics for children with epilepsy. Children with suspected epilepsy are referred to Edendale and Grey‟s hospital Paediatric Outpatient Department for their assessment from primary health care clinics, level 1 and level 2 hospitals. Health care workers managing children with suspected epilepsy do not adhere to childhood epilepsy guidelines and protocols and therefore find epilepsy a difficult condition to manage. The purpose of this clinical audit was to assess the quality of care of children referred to Edendale and Grey‟s hospital with suspected epilepsy. Information obtained from this audit will be used to improve the quality and consistency of patient care and therefore reduce childhood morbidity and mortality from the complications of epilepsy among children in Area 2, KwaZulu-Natal. Materials and Methods The Paediatric Outpatient Department registers at Edendale and Grey‟s hospital were used to identify children referred with suspected epilepsy, and their case notes were retrieved. Children who met the inclusion criteria for the study were: i) those referred to the Paediatric Outpatient Department, Neurodevelopment or Epilepsy clinics for their first assessment with a diagnosis of suspected epilepsy and ii) children aged 14 years at Grey‟s hospital and 10 years at Edendale hospital. Children excluded from the study were those i) with febrile convulsions; ii) who had repeat visits and iii) not referred with suspected epilepsy. MN Madekurozwa v Letters from referring hospitals and patient case notes were reviewed and this information was used to fill in the audit forms. A modified British Paediatric Neurology Association audit tool was used for the study. The study period covered was from January 1st 2004 to January 31st 2006. Results From the two-site audit, 232 folders were retrieved and of these 119 case notes met the inclusion criteria and were reviewed, 83 from Edendale and 36 from Grey‟s hospital. The median age of the patients at Edendale hospital was 4-years (age range 2-months to 10-years) at Grey‟s hospital the median age was 3-years (age range 8-months to 12-years). Sixty-six patients were male and fifty-three were female. At Edendale hospital, the majority of patients, 88% were seen within a week of referral, with only 2% seen more than a month later. Of these patients, 37% were assessed by interns and 16% by paediatricians. At Grey‟s hospital the majority of patients were seen more than a month after booking for their first assessment and were assessed by registrars (35%), paediatricians (28%) and senior medical officers (14%), none of the patients were assessed by interns. From reviewing the history, examination, diagnosis, treatment, communication and future care it was found that the overall care of children presenting with suspected epilepsy to both hospitals was poor. Conclusion This was a retrospective study that relied on the availability and review of patient case notes and adequate documentation by the assessing health care workers. The findings from this audit suggest that the quality of care of children presenting with suspected epilepsy to Edendale and Grey‟s hospital is inadequate, with a lack of adherence to guidelines as shown by the lack of adequate statements from history taking, diagnosis, inappropriate use of investigations and inadequate counselling on treatment and future patient care. To improve the management of children referred with suspected epilepsy there should be an improvement in health care worker training to ensure that epilepsy guidelines are adhered to. There should also be an improvement in caregiver and child counselling and education; and strengthening of systems - record keeping, research, and audit with a regular review of epilepsy guidelines.

Thesis (MCur)--Stellenbosch University, 2000. / ENGLISH ABSTRACT: Recent escalation of medical costs, cost containment and decreasing public funds, drew attention to the importance of formulation and evaluation of standards of nursing care. Practice experience and consultations with nurse managers indicated a great need for standards to evaluate the quality of care in the pediatric units of the big hospitals in Swaziland. A non-experimental, explorative and descriptive study was conducted in the four regional hospitals in Swaziland. Checklists were developed by the researcher to evaluate standards of care relating to the structure, process and outcome dimension of care. Structure standards refer to minimum requirements regarding the facilities, equipment, supplies, and availability of generic documents and staff. Process standards are mainly concerned with the specific nursing procedures and practices, while the Outcome standards evaluate the parents' satisfaction with the nursing care of their child, the amount of information received prior to discharge and the level of communication between the parents and the nursing staff. The most important results are: .:. None of the hospitals met the pre-set requirement to be considered as delivering a satisfactory level of care for any of the three dimensions of care . •:. Critical nursing procedures were often performed ineffectively and inefficiently . •:. Most parents viewed their communication with the nursing staff negatively. Recommendations include the development and implementation of a formalized quality improvement programme on all levels of care, auditing of records and patient care and in-service education for all personnel regarding quality care. Keywords: Quality care, formulation and evaluation of standards - pediatric patients / AFRIKAANSE OPSOMMING: Die onlangse verhoging in mediese koste, kostebesparings en verminderde openbare fondse, het die aandag gevestig op die belang van formulering en evaluering van standaarde vir verpleegsorg. Praktykervaring en konsultasies met verpleegbestuurders het aangedui dat daar 'n groot behoefte bestaan vir standaarde om die gehalte van verpleegsorg in pediatriese eenhede in die groot hospitale van Swaziland, te evalueer. 'n Nie-eksperimentele, verkennende en beskrywende studie is onderneem in die vier streekshospitale in Swaziland. Kontrolelyste is deur die navorser ontwikkel om standaarde van sorg te evalueer ten opsigte van die struktuur-, proses-, en uitkomsdimensie van sorg. Struktuurstandaarde verwys na die minimum vereistes ten opsigte van die fasiliteite, toerusting en voorrade, die beskikbaarheid van generiese dokumentasie en die personeel. Prosesstandaarde hou hoofsaaklik verband met spesifieke verpleegprosedures en praktyke terwyl Uitkomsstandaarde die ouers se tevredenheid met die verpleging van hulle kind, die hoeveelheid inligting ontvang voor ontslag en die vlak van kommunikasie tussen die ouers en die verpleegpersoneel evalueer. Die belangrikste resultate is: .:. Geen hospitaal het ten opsigte van enige van die drie dimensies van sorg, aan die voorafbepaalde vereiste voldoen om beskou te word dat hulle 'n bevredigende vlak van sorg lewer nie . •:. Kritiese verpleegprosedures is dikwels oneffektief en ondoeltreffend uitgevoer. .:. Die meeste ouers het fn negatiewe siening gehad ten opsigte van die kommunikasie met die verpleegpersoneel. Aanbevelings sluit in die ontwikkeling en implementering van fn geformaliseerde gehalte verbeteringsprogram op alle vlakke van sorg, oudit van rekords en pasiëntsorg en indiensopleiding vir alle personeel ten opsigte van gehaltesorg. Sleutelwoorde: Gehaltesorg, formulering en evaluering van standaarde - pediatriese pasiënte

Magister Curationis - MCur / Globally, there has been significant progress in reducing preventable maternal deaths and disability, and growing attention on improving the quality of care in maternal health care facilities. The World Health Organization (WHO) describes quality care as delivering healthcare that is effective, efficient, accessible, acceptable, patient–centred, equitable and safe (WHO, 2014). Midwives are the backbone of midwifery and therefore the primary care giver for pregnant women accessing maternal care and women’s ability to access quality midwifery care during the antenatal, labour and postnatal period is the key component in midwifery care. The Primary Level Protocol of South Africa is under the umbrella of the Primary Health Care System, and according to this system low risk women are expected to seek antenatal, intrapartum and postnatal care from the nearest Midwife Obstetric Unit (MOU). The choice a woman makes regarding access to maternity care depends on the social norms in her society and what services are offered. However, the services that are available may not meet the needs of pregnant women. Women may need detailed information about the availability of the maternity care system in order to make an informed decision on where to access the health system. The gap between the perceived needs of pregnant women and the care provided by midwives can be bridged by listening to women to create a reciprocal understanding of quality care. In South Africa, limited research has been conducted on midwives and women’s perceptions of maternity care. In the absence of such information, this study was conducted at an MOU in the Western Cape, with the aim of exploring women and midwives’ perceptions of quality care during childbirth.

Há anos a redução da taxa de mortalidade materna vem sendo discutida em todo mundo, sendo considerada um dos indicadores de qualidade à saúde. É consenso mundial que a presença de profissionais qualificados durante o ciclo gravídico-puerperal diminui o número das morbi-mortalidades de mulheres e recém-nascidos. Diante desta situação a Confederação Internacional das Parteiras (ICM) preconizou as competências essenciais que os profissionais devem possuir para realizar uma atenção qualificada em todas as fases do ciclo reprodutivo. Objetivo: descrever o perfil dos profissionais de enfermagem que atuam na assistência de enfermagem durante o trabalho de parto, parto e pós parto imediato no município de Piracicaba/SP e identificar os procedimentos que estes realizam segundo a preconização da ICM. Metodologia: estudo quantitativo de natureza descritivo-exploratória. Os dados foram coletados em duas instituições. Foram entrevistados através de questionário semi-estruturado 57 profissionais: 8 enfermeiros obstetras, 4 enfermeiros, 38 técnicos de enfermagem e 7 auxiliares de enfermagem. Através de observação não participativa foram acompanhados 24 acolhimentos para primeiro atendimento, 30 trabalhos de parto, 20 partos e pós partos imediato. Para análise dos dados foi utilizada a estatística descritiva. Resultados: Perfil da equipe de enfermagem: todos profissionais são do sexo feminino, com média de idade de 30 anos, 45,61% convivem com parceiro fixo, 57,89% não possuem filhos, média diária de trabalho de 7,42 horas, 77,19% destes participaram de eventos científicos após conclusão dos seus estudos, apenas profissionais com nível superior realizaram partos. Todos afirmaram gostar de trabalhar na assistência ao parto. Competências essenciais: em geral, as práticas obstétricas recomendadas pela Organização Mundial de Saúde (OMS) são adotadas, embora em muitas situações estas sejam realizadas de maneira incompleta em especial as que se referem à humanização da assistência. No entanto, notou-se que as atribuições são delegadas segundo categoria profissional e não em relação à competência profissional. Conclusão: o estudo demonstrou a necessidade de abolir a divisão das funções segundo formação profissional, permitindo que o atendimento seja realizado de acordo com a qualificação profissional em especial no que se refere ao atendimento a mulher durante o parto. Há necessidade de investimentos na reciclagem dos profissionais e na reorganização do modelo da assistência para contribuir com a melhoria da assistência durante o trabalho de parto, parto e pós-parto imediato no município de Piracicaba/SP. / For years, the reduction of maternal mortality has been globally discussed and is considered one of the indicators of quality of health. It is a global consensus that the presence of trained professionals during the pregnancy-puerperium cycle decreases the number of morbidities and mortalities of women and newborns. Thus, the International Confederation of Midwives (ICM) recommended the essential competences that professionals should have to provide quality care in all phases of the reproductive cycle. Objective: to describe the profile of nursing professionals who work in nursing care during labor, delivery and immediate postpartum in the city of Piracicaba-SP, and to identify the procedures they perform according to the recommendation of the ICM. Method: quantitative, descriptive and exploratory study. Data were collected in two institutions. Using a semi-structured questionnaire, 57 workers were interviewed: 8 nurse-midwives, 4 nurses, 38 nursing technicians and 7 nursing auxiliaries. Through non-participatory observation, 24 first welcomes, 30 labors, 20 deliveries and immediate postpartum were followed. Descriptive statistics was used for data analysis. Results: Nursing team profile: all workers are female, with average age of 30 years, 45.61% have fixed partners, 57.89% do not have children, the average daily workload is 7,42 hours, 77.19% of them participated in scientific events after finishing their studies, and only workers with higher education performed delivery care. All participants reported liking to work in delivery care. Essential competences: in general, the obstetric practices recommended by the World Health Organization (WHO) are adopted, although in several situations they are carried out incompletely, mainly the ones referring to the humanization of care. However, it was noticed that the attributions are delegated according to professional category and not in relation to professional competence. Conclusion: the study showed the need to extinguish the division of functions according to professional degree, permitting care to be delivered according to professional qualification, especially with regard to care to women in delivery. Investment in professional recycling and in the reorganization of the care model as to improve care during labor, delivery and immediate postpartum in the city of Piracicaba/SP is needed.

There is a lack of quality communication among health care professionals and patients in the hospital setting, which can negatively impact patient satisfaction and increase hospital readmission rates. Interdisciplinary bedside rounding (IBR) is a method of rounding that uses direct communication and discussion of the patient at the bedside, and the use of IRB may improve the quality communication among health care professionals and patients. The purpose of this program outcomes evaluation project was to evaluate whether IBR increased patient satisfaction with nursing communication and if IBR decreased hospital readmission rates. The Iowa model of evidence-based practice provided a framework that was used for this project. This program outcomes evaluation used a retrospective pre-post design to collect data 3 months prior to and 3 months following IBR on 1 medical surgical hospital unit. A convenience sample of 42 IBR patient participants was used. HCAHPS scores were used to evaluate patient satisfaction with nursing communication, with a percent of change comparison evaluated. Thirty day readmission rates were evaluated using a hospital based data set and a direct comparison of data was performed. Findings revealed that IBR did not improve patient satisfaction with nursing communication overall. In regards to hospital readmissions, 1% of the hospital readmissions were from the IRB group versus 10% hospital wide. Those who experienced IBR were less likely to return within 30 days. The use of the IBR program and resultant reduced readmission rates show promise for positive social change by improved patient outcomes and decreased health care costs for all.

Community Health Centers (CHCs) are the nation's primary care safety-net for vulnerable populations, including racial/ethnic minorities, migrant workers and the uninsured. Women from these populations contribute disproportionately to cervical cancer morbidity and mortality, largely due to underutilization of Pap smear screening. The purpose of this cross-sectional study was to identify factors that may be related to Pap smear screening compliance among a large cohort of women seen at 10 Community Health Centers in Florida. Building upon an ecologic framework, this research went beyond patient-level risk factors, which are generally well-known, and explored provider and organizational variables that may also be associated with Pap smear screening compliance in this population. Ten CHCs in Florida met study inclusion criteria of having at least four complete years of claims and patient registration data stored in an Electronic Health Record (HER) data system maintained at HCN. EHR data were merged with provider gender obtained from a credentialing database and with data from a short organizational survey administered to the Medical Directors of the CHCs. Descriptive statistics, chi-squared analysis, and multiple logistic regression were used to examine Pap smear screening rates for women (n=71,234) in relation to a variety of patient, provider and organizational variables. Younger, Hispanic and insured women were most likely to have had a screening in the past three years compared to older, white non- Hispanic and uninsured women. Among providers, patients who received care from female providers generally had higher Pap smear compliance rates, but these findings differed by patient insurance and race/ethnicity group. Organizational factors that appeared to be associated with higher Pap compliance rates included diffusion of an EHR system, implementation of "Care Model Principals", and having recently implemented a Pap smear screening process improvement project. Results demonstrated that multi-level factors, operating on the patient, provider and organizational levels, contribute to Pap smear compliance among women seen at CHCs. Results suggested that improving screening compliance within this population of women requires interventions that are ecologic in scope, incorporate targeted education to high-risk women and providers, and include organizational strategies that can optimize care delivery at point-of-care.

This thesis is concerned with the quality of care for the elderly in nursing homes, responding to a critical social and demographic imperative. The aim of this study is to provide a service quality construct for nursing homes to increase client focus and satisfaction. The research is underpinned by the service quality literature. It utilises the SERVQUAL construct to explore the nature of service quality in nursing homes through semi-structured interviews with nursing home residents and resident's families. A service quality scale was constructed comprising six dimensions and 27 scale items capturing service delivery in nursing homes. This scale was purified through a survey of residents and family members (n=263). Through exploratory factor analysis, six importance and four experience factors were identified. Regression analysis was used to identify relationships between the factors, service quality and satisfaction. The results indicate that importance does not predict perceived quality, though experience of responsiveness and hospitality and courtesy and personal approach are indicators of service quality. Furthermore, quality emerges as a predictor of satisfaction. From these outcomes, a service quality construct was developed which comprises of service marketing and service quality dimensions. This thesis contributes to the construction of the concept of service quality in nursing homes, its dimensionality and thus the precursors of satisfaction. These have considerable implications for the management of nursing home services.homes, its dimensionality and thus the precursors of satisfaction. These have considerable implications for the management of nursing home services.

Over the last decade out-of-home care in Australia has experienced a period of considerable turmoil as royal commissions, parliamentary inquiries, departmental audits, empirical research and industry reports have highlighted the dire straits of the care system. A constant theme throughout has been the failure of the sector to adequately meet the needs of children and young people in care. Within this context the purpose of this study was to examine the needs of children and young people in care in Australia, giving voice to the full range of stakeholders, whose views were expressed in multiple documentary types. Specifically, the aim was to develop an in-depth understanding of their needs and formulate this into a formal taxonomy of needs. Using document analysis and the constant comparative method within the constructivist paradigm of social inquiry, the study involved analysis of 580 non-traditional, naturalistic and secondary documents relating to out-of-home care in Australia. The document sample consisted of five data types: primary data (letters, submissions to inquiries, transcripts of interviews and public hearings, and personal accounts); secondary data (reports resulting from commissions of inquiries and departmental reviews, audits and investigations); empirical data (the published findings from empirical research); legislative and policy data (legislation, regulation and quality frameworks); and industry and practitioner data (reports by academics, peak bodies and advocacy groups, and writings by out-of-home care practitioners). Further, the document sample included stakeholders from five major groups: children and young people in care (and former wards ); their parents and extended family; carers, agency staff and practitioners; statutory workers; and academics, advocates, and representatives of state and national peak bodies. The findings include a series of prominent themes of care; salient findings that highlight the experiences and needs of children and young people in care; and the taxonomy of needs. The prominent themes include the importance of natural family connectedness, cultural identity and connectedness, and counselling and therapeutic support. Issues relating to placement stability and disruption, safety and protection and, transition from care also featured prominently. The salient findings include an exploration of the overwhelming emotions of care, emotional putdowns, vicarious trauma and the witnessing of violence and abuse in out-of-home care, characteristics of children and young people who survive and thrive in care and beyond, characteristics of quality carers, symptom intolerance, disenfranchised grief – the never-ending story, and the defensive behaviours of children and young people in care. The taxonomy of needs provides a comprehensive overview of the needs of children and young people in care across 89 attributes and 21 attribute sub-categories, within 21 dimensions, and across three domains (the personal, placement, and community-of-care domains). The dimensions in the personal domain include attachment, physical development and health, personal growth, education and vocational attainment, development of the inner-self, and hope in life and for the future. The placement domain includes basic needs, basic entitlements, caring relationships, positive-parenting-practices, activity programming, focused-support, peer-relations and positive group management, and preparation for and transition from care. The community-of-care domain includes clinical intervention, family connectedness and involvement in placement, friends and social outlets, significant others, cultural-religious-spiritual connectedness, departmental worker capacity and support, and after care support. The principal theoretical, practice, and methodological conclusions derived from this study are that children and young people in care in Australia have considerable needs, are largely unable to meet their own needs, and experience harm when their needs are not met. Consequently, the out-of-home care sector has an inescapable obligation to provide for these needs if children and young people in care are to avoid harm and experience personal wellbeing. Further, children and young people in care have experienced considerable need deprivation, and if their needs are not to be forgotten, then a shift to a ‘needs-based’, ‘needs-focused’ paradigm of care is needed to inform out-of-home care policy, service design, and day-to-day practice. And finally, document analysis using non-traditional, naturalistic, and secondary data (representing the full range of stakeholder perspectives) within a constructivist paradigm of inquiry, provides an effective, indeed powerful methodology for exploring the needs of children and young people in care, and for giving voice to the many stakeholders who voices may never have been heard again.

Over the last decade out-of-home care in Australia has experienced a period of considerable turmoil as royal commissions, parliamentary inquiries, departmental audits, empirical research and industry reports have highlighted the dire straits of the care system. A constant theme throughout has been the failure of the sector to adequately meet the needs of children and young people in care. Within this context the purpose of this study was to examine the needs of children and young people in care in Australia, giving voice to the full range of stakeholders, whose views were expressed in multiple documentary types. Specifically, the aim was to develop an in-depth understanding of their needs and formulate this into a formal taxonomy of needs. Using document analysis and the constant comparative method within the constructivist paradigm of social inquiry, the study involved analysis of 580 non-traditional, naturalistic and secondary documents relating to out-of-home care in Australia. The document sample consisted of five data types: primary data (letters, submissions to inquiries, transcripts of interviews and public hearings, and personal accounts); secondary data (reports resulting from commissions of inquiries and departmental reviews, audits and investigations); empirical data (the published findings from empirical research); legislative and policy data (legislation, regulation and quality frameworks); and industry and practitioner data (reports by academics, peak bodies and advocacy groups, and writings by out-of-home care practitioners). Further, the document sample included stakeholders from five major groups: children and young people in care (and former wards ); their parents and extended family; carers, agency staff and practitioners; statutory workers; and academics, advocates, and representatives of state and national peak bodies. The findings include a series of prominent themes of care; salient findings that highlight the experiences and needs of children and young people in care; and the taxonomy of needs. The prominent themes include the importance of natural family connectedness, cultural identity and connectedness, and counselling and therapeutic support. Issues relating to placement stability and disruption, safety and protection and, transition from care also featured prominently. The salient findings include an exploration of the overwhelming emotions of care, emotional putdowns, vicarious trauma and the witnessing of violence and abuse in out-of-home care, characteristics of children and young people who survive and thrive in care and beyond, characteristics of quality carers, symptom intolerance, disenfranchised grief – the never-ending story, and the defensive behaviours of children and young people in care. The taxonomy of needs provides a comprehensive overview of the needs of children and young people in care across 89 attributes and 21 attribute sub-categories, within 21 dimensions, and across three domains (the personal, placement, and community-of-care domains). The dimensions in the personal domain include attachment, physical development and health, personal growth, education and vocational attainment, development of the inner-self, and hope in life and for the future. The placement domain includes basic needs, basic entitlements, caring relationships, positive-parenting-practices, activity programming, focused-support, peer-relations and positive group management, and preparation for and transition from care. The community-of-care domain includes clinical intervention, family connectedness and involvement in placement, friends and social outlets, significant others, cultural-religious-spiritual connectedness, departmental worker capacity and support, and after care support. The principal theoretical, practice, and methodological conclusions derived from this study are that children and young people in care in Australia have considerable needs, are largely unable to meet their own needs, and experience harm when their needs are not met. Consequently, the out-of-home care sector has an inescapable obligation to provide for these needs if children and young people in care are to avoid harm and experience personal wellbeing. Further, children and young people in care have experienced considerable need deprivation, and if their needs are not to be forgotten, then a shift to a ‘needs-based’, ‘needs-focused’ paradigm of care is needed to inform out-of-home care policy, service design, and day-to-day practice. And finally, document analysis using non-traditional, naturalistic, and secondary data (representing the full range of stakeholder perspectives) within a constructivist paradigm of inquiry, provides an effective, indeed powerful methodology for exploring the needs of children and young people in care, and for giving voice to the many stakeholders who voices may never have been heard again.